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Is Practice Fusion in a partnership with Google?

Several blogs and newspapers recently reported that Practice Fusion is partnering with Google, which will provide targeted ads for Practice Fusion's EHR solution. However, while everyone is wondering when and how Google will be getting into Health IT, Google is not (yet) entering the EHR market. Most importantly, Practice Fusion’s business model is trivial to implement using free software. Read on for the all the gory technical details.

The Google Partnership

Google is not partnering with Practice Fusion any more than they are partnering with any AdSense website allowed to use the Adsense API (only sites with more than 100000 page views per day are allowed to use Adsense API).

While the idea of using advertising to fund an EHR is interesting, the technology behind it is trivial.

It would take me about an hour to replicate this business model using the GPL MirrorMed (or ClearHealth, OpenEMR, TORCH etc. etc.) However, it wouldn't be using the advanced Adsense API, but a simple separate frame.

After reading marketing material from Practice Fusion, many reporters believed that the EHR provider had a special relationship with Google. Of course, since your average journalist does not know a bit from a byte, they didn’t even know how to investigate further, and the second hand journalism (and sadly blogging) made Practice Fusion look like Google’s new health care partner, which, of course, they are not.

When I first saw the announcement I thought, “There’s no way they would announce this just because they signed up for AdSense... right?” Wrong. Despite countless press-release regurgitating journalists commenting on the deal and a blogosphere abuzz with “Google’s entry into the EHR market”, at least Andis Robeznieks over at Health IT Strategist (HITS) apparently knew what questions to ask whom. In the March 19th 2007 edition of HITS, he posted a quote from Google’s Brandon McCormick. From the article:

“Practice Fusion has recently joined Google’s AdSense program to place ads on their Web pages,” McCormick said in an e-mail. “AdSense helps hundreds of thousands of publishers effectively monetize online content in just about every vertical category that exists on the Web. Practice Fusion’s participation in our AdSense program is not exclusive and should not be read as an indication of any product plans by Google.”

Translation: Google is not doing anything special for Practice Fusion that they would not do for anybody with at least 100000 page views a day. As I will explain shortly, you don't actually need the Adsense API to reach the same goal (simply by using frames).

Is this a particularly innovative strategy? Not really. It would be pretty aggressive if they were considering this as their only source of income, but they plan on offering standard support too.

This funding model is trivial to implement using free, GPLed software

Which is, of course, why I am writing this here! The “innovation” that Practice Fusion has figured out how to get Google ads to appear without broadcasting HIPAA covered data over the internet. They did so using the Adsense API. However, to get this to work in MirrorMed (a GPL-available PHP-based EHR that I contribute to), you simply need to understand how frames work with Google Ads. Google Ads scan the content of the web page that they live in to provide “targeted” advertising. Very likely you might see ads for Electronic Health Records on Free Software Magazine since I am discussing them in this text. Google is aware of the text on the same HTML page and delivers ads that might be interesting in the context of that HTML. However, it only looks inside a particular frame.

So, if John Doe with a social security of 123-12-1234 appeared in a web-based EHR with Google ads, both the name and the social security number would be transmitted to Google across the internet in cleartext, which is what we in the HIPAA security business like to call “bad”. One cannot just stick Google ads on a page with HIPAA covered data on it. What you can do is create two frames or iframes for your EHR. On one, which we can call the EHR frame, you put HIPAA data like name, address, phone and social security numbers. On the other frame, the ad frame, you put patient conditions without identifying data. For instance, if a patient was suffering from high cholesterol, the ad frame might have the term, “High Cholesterol” written at the top. Below those terms, which would match to the current patients conditions, would be AdSense ads that would target those terms. For instance, Google might serve an ad for Lipitor in response to the term “High Cholesterol”. Voilà, Google ads without violating HIPAA.

Granted, Practice Fusion uses the Google Ads API directly, rather than using a frames based system. If you feel that my method above is a hack (because it is) then you can query Google Adsense API on the server side and present Google Ads within the same frame as your EHR content. This is a lot cleaner but not that much harder than what I have described above

To fully compete with Practice Fusion go rent a server at ServerBeach for $75 dollars a month, install MirrorMed and hack it up to present your two frames. Make sure you backup your HIPAA covered data, and start marketing your “partnership” to provide an EHR with Google. The only difference between you and Practice Fusion would be: 1) You are not using the Adsense API 2) that you are leveraging GPL Electronic Health Records on a GPL operating system, which 3) might give you a shot in hell at being profitable using only Google ads

As per the Fred Trotters comments, this article was toned down on 3-21-08 by Tony Mobily and Fred Trotter.

I would love to see how this story ends. Thanks you for responding, Fred!
One note: I couldn't find the forums where Jonathan is answering questions. THe link you provided here is just to the home page... do you have a more precise link?

I normally am a spectator in these forums and have never commented but thought this thread was of particular interest and given the turn it has taken I feel I have to comment. I actually just got through getting a quote for a new PM/EMR system that was opensource and 'free'.

Fred - What I think is interesting is your hostility in both of your postings. Its interesting to see you trash-talk their model, particularly when you have an inherent conflict of interest. The reality is that you are a vendor. In fact according to you recent interview found here "$30,000 in Customizations Minimum"
You clarify that you charge to implement, customize and support your open source software – to quote you “I do a lot of software customization for MirrorMed, and when I sell it, I usually charge around $30,000 as a minimum.”

It's obvious you feel threatened by their model and you should. Your actions honestly show a true lack of professionalism. The fact that you would under the guise of being a consumer advocate, publicly bash a competitors solution not once, but continually, even after your base issues were addressed, in my opinion shows a dangerous lack of either good judgment or personal integrity both of which I consider essential in a potential vendor.

Please don't bother saying that FOSS or any of your other opensource software is free - because its not. Anyone using opensource is forced to pay endless consulting fees and on-going maintenance to get a product that is actually usable in a clinical group environment. The truth is you are the only snake-oil salesman here. You bait your prospects with free and then switch them with never ending customizations and support fees.

Also, I have looked at your site and if this is best you can show you should do less posting and more coding. Here is a link Mirrormed

I personally think Jonathan has represented his company well (I also noticed that you didn't have anything to say after his last comments). Will it work? Only time will tell, but I think they may be on to something. You, on the other hand, should be a man and retract your comments. They make you look bad and that will only hurt your business. If you want to bash me feel free but keep in mind you started this negative thread.
Dr. Kon Bökamp

Dr. Bökamp
You point out that I am biased because I sell GPL software. This is true, I am biased. I do not think this effects the strength of my arguments one way or another. Generally I do not feel particularly threatened by the Practice Fusion Model. As I hope I showed in the article, it is pretty easy for me to change my model to match theirs, which I will do in a heartbeat if I ever thought that might work.

As for bashing a competiting vendor: yes I do alot of that. I believe firmly that software should be totally readable by clients and under the GPL, and I "bash" anyone who disagrees with that.

So far my "base issue" has only been partially addressed, and in fact now I have new issues with Practice Fusion. Because my base issue was "partially" addressed I will likely put forward a "partial" retraction.

As for saying that my software is "free" I rarely if ever say that. Mostly for exactly the reasons that you describe, my software is typically very expensive. When I say "free" I usually mean "free as in freedom", if you have a concrete example of me implying "costless" when I say free I will do my best to fix that.

As for bait and switch, I think you will find that I make it perfectly clear to my clients that my solutions are expensive, in fact you found a place where I quoted my expensive price. I am not sure how you can accuse me of both being too expensive, and guilty of bait and switch.

I respect the fact that Jonathan has been posting to the forums, (and you will find that our discussion continued quite a bit over on emrupdate) but I do have some problems with the way he talks about his product.

I typically reserve "bashing" for really really stupid ideas. I bashed Practice Fusion because it seemed like they thought they could falsely claim that they had a "partnership" with Google. This, to me, qualifies as really really stupid. Jonathan is claiming, essentially, that this claim was a reporters mistake. Then proceeds to try and convince me that they are real with "buzzwords". Buzzword marketing is something that qualifies to me as really really stupid.

You do not seem really really stupid. And I hope it is clear that I am not bashing you. You obviously have some valid concerns and I would say that you were a bit harsh, but then so was I, so who am I to criticize that?

I have had some limited dealings with Practice Fusion, and the experience has been troubling, to put it kindly.

First, the program is not "free." Once you get past the marketing hype and actually try to sign up for the program, you are informed that there is a mandatory $50 per month per provider "support" fee. This is a little disingenuous as all of their marketing hype expounds on how easy the program is to use and how it is virtually maintenance free.

Second, I've been following these guys since the first of the year when they hit the edges of the EMR radar. Initially when I contacted them they told me that they were concentrating on large groups and RHIO's, and that they would notify me when they would start moving the program down to smaller practices. However, when I talked to them a few days ago, the story was just the opposite - they told me that they weren't ready for large groups and that they were concentrating on practices of fewer than 20 providers. I have the emails going back to the first of the year to substantiate this. In fact, I know of no group that has bought into their program, and they have not been able to provide me with any reference sites to contact.

Third, their program is an ASP version of an older program called Medical Chart Wizard - not exactly a program that set the EMR market on fire prior to being "acquired" by Practice Fusion - and despite hyping their service for the better part of a year, they didn't even acquire Medical Chart Wizard until July of this year. They have been hyping their "Free EMR" since March (maybe even before that). This was basically "vaporware" that they hyped most of this year. Actually they have given me several differing versions of what they are doing. At one time they told me it was not a true ASP program, but a “hybrid” program with a version that the physician could purchase that did not collect data or present ads.

I tried to get a number of question answered on behalf of a group of physicians I consult with, including:

1: Training – How do you intend to facilitate new-user training? Most PM/EMR’s require new enrollees to take 3-5 days of training (usually on-site with one of their trainers, but some are via webinars).

2: How will training be scheduled, and how will it be charged. Is it included with the support subscription, or priced separately?

3. What type of internet connection does the client need? Should the client provision T1? Can they use broadband? Will your program support a dual wan configuration, where the client has 2 ISPs for failover? For instance, cable and a failover DSL line (a common configuration for ASP installations is Roadrunner business-class cable on a dual WAN firewall/router with either Verizon or ATT DSL for failover). I can tell you that the hospital is going to require affiliated physicians on ASP or hybrid programs to either have T1 or broadband with failover.

4. Client setup and installation – Can clients add or remove workstations from the program on their own or through their IT provider? How is the client software installed on the client’s workstations? What are the minimum and recommended workstation hardware requirements?

5. If the program doesn’t work out, or your company goes under (that happens, unfortunately. I know several practices that had purchased AcerMed and are now out substantial investments), what is the procedure for exporting the data from your program and what formats can the data be exported to? Can the clients export their own data, or have their IT service export the data for them? I know that after the AcerMed fiasco a few months back that this is going to be a very important question.

6. What are the procedures for importing data? Can the client or the client’s IT service import data for themselves? If not, is there a standard format that the client can submit data for import (like CSV or comma separated values). Most of the 1,100 physicians that I work with through the hospital already have demographic data in the current PM. A few have emr data as well. Most of the programs that are currently being used are SQL based. It is relatively straightforward to run a SQL script to export the existing data into a CSV file in the field order
corresponding to the new program – for demographic data anyway. Appointment data and emr data is sometimes more difficult, depending on the program.

7. Can you give me more information on implementing your program within an RHIO? Can the RHIO train their existing IT staff to handle Tier-1 and possibly Tier-2 support requests from RHIO members? Can you give me a little more specific information on the Physician Relationship Management Service Dashboard and the Point-of-Integration Service?

8. Have you received CCHIT Certification for your program?

They would not respond to the questions. Nor would they allow me an opportunity to use the program hands-on to judge the efficiency of their hosting, and whether dictation and document scanning were feasible (even some of the best ASP solutions have difficulties providing enough bandwidth where practices scan a lot of documents or do a lot of dictation with Dragon).

Originally they represented to me back in March that the ads were controlled by them and were subscribed to by pharma, medical suppliers and providers. Now the model is Google AdSense. No way am I going to recommend something like that to a physician. I don't see how that they can make this model compliant with the HIPAA Security Rules (45CFR 164) for the Physician without fully disclosing and documenting for the physician exactly how PHI is segregated and protected, and exactly what information is being aggregated and sold.

They also told me that they had something like a thousand doctors already on board. But they could not provide me any reference sites, and I suspect that this user base is actually the old Medical Chart Wizard users.

Mostly, these guys are full of it – and full of themselves.

I was initially very receptive of their idea, but after some due diligence I unfortunately have to recommend avoiding Practice Fusion like a plague.

I've helped clients use Adsense to help defray the costs of their web presence. So in adition to my other concerns, I don't see the numbers really adding up if Practice fusion expects to profit by using Adsense imbedded in their SaaS EMR. This model relies on the users clicking on those ads and visiting the websites. But really, what doctor has the time for that distraction? And what medical office is going to put up with staff spending time cruising around the web? Patient visits and productivity are what make and break a practice. Most doctors I work with (and this can be verified by visting the user boards for most EMR's) want to input data in the least amount of time with the fewest distractions. There are whole threads on the internet by doctors devoted to reducing clicks per visit in their EMR's. Given that, how many practitioners are realy going to spend time clicking on those adds to generate revenue for PF? And btw, it is a violation of the Adsense usage agreement to actively encourage vistors (or users) to click on ads. Those advertisors have to pay for those clicks. Encouraging clicks soley to generate revenue for another party is fraud. Google's policy is to suspend an Adsense subscriber that actively encourages clicks, or that click on their own or other ads excessively. Its going to take a lot of clicks for each provider to generate enough revenue for PF to offset the bandwidth and hosting requirements from even a moderately busy provider. It doesn't add up.

General security and work rules in a medical practice also work against this model. Most facilities and practices I work with have strict restrictions on users accessing the web, and many require me to block access to all but the websites that are approved by group policies (GPO's). Any competant IT consultant strongly encourages restrictive GPO's - because most viruses and spyware come into the systems via the internet and browsers. In fact, most spyware is transmitted via web browsing. That is why to really be HIPAA Security compliant Web browsing should be locked down to known safe sites and strictly monitored. Once you have a spyware infection, all of your patient data can be potentially compromised. This is how the recent TD Amertrade "secure" data was stolen - by spyware introduced into their system.

Productivity also works against this model. Most providers already complain about the time lost having to log into computers in compliance with the HIPAA security rules. Thirty seconds to a busy provider is agonizingly long. In most facilites and practices, there are documented sanctions for employees caught "surfing" the web. Productivity makes a practice profitable. What practice is going to encourage, or even allow, staff to spend time clicking on ads and actually exploring the ads website? Most employees get two 10-minute breaks (besides lunch) during a workday. Just reviewing one or two ads can easily eat up that much time. Web surfing is the single biggest productivity drag in organizations that don't strictly control it. That has been documented in several studies.

Practice Fusion's business model relying on Google Adsense to generate the bulk of its revenues just does not ad up. It runs counter to Best Practices, both in terms of productivity and security, in a medical practice.